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Self-medication
:This article is about the self administration of drugs in humans. For the operant study of self reward in animals see: Self-administration. Self-medication is a human behavior in which an individual uses unprescribed drugs to treat untreated and often undiagnosed medical ailments. The psychology of such behavior within the specific context of using recreational drugs, psychoactive drugs, alcohol, and other self-soothing forms of behavior to alleviate symptoms of mental distress, stress and anxiety, including mental illnesses and/or psychological trauma, is particularly unique and can serve as a serious detriment to physical and mental health if motivated by addictive mechanisms. Self-medication is often seen as gaining personal independence from established medicine,Benefits and risks of self medication and it can be seen as a human right, implicit in, or closely related to the right to refuse professional medical treatmentThree arguments against prescription requirements, Jessica Flanigan, BMJ Group Journal of Medical Ethics 26 July 2012, accessed 20 August 2013 Definition Generally speaking, self-medication is defined as "the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms" Psychology and psychiatry Self-medication hypothesis As different drugs have different effects, they may be used for different reasons. According to the self-medication hypothesis (SMH), the individuals' choice of a particular drug is not accidental or coincidental, but instead, a result of the individuals' psychological condition, as the drug of choice provides relief to the user specific to his or her condition. Specifically, addiction is hypothesized to function as a compensatory means to modulate effects and treat distressful psychological states, whereby individuals choose the drug that will most appropriately manage their specific type of psychiatric distress and help them achieve emotional stability.Khantzian, E.J. (1997). The self-medication hypothesis of drug use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231-244.Khantzian, E.J. (2003). The self-medication hypothesis revisited: The dually diagnosed patient. Primary Psychiatry, 10, 47-48, 53-54. The self-medication hypothesis (SMH) originated in papers by Edward Khantzian, Mack and Schatzberg,Khantzian, E.J., Mack, J.F., & Schatzberg, A.F. (1974). Heroin use as an attempt to cope: Clinical observations. American Journal of Psychiatry, 131, 160-164. David F. Duncan,Duncan, D.F. (1974a). Reinforcement of drug abuse: Implications for prevention. Clinical Toxicology Bulletin, 4, 69-75. and a response to Khantzian by Duncan.Duncan, D.F. (1974b). Letter: Drug abuse as a coping mechanism. American Journal of Psychiatry, 131, 174. The SMH initially focused on heroin use, but a follow-up paper added cocaine.Khantzian, E.J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142, 1259-1264. The SMH was later expanded to include alcohol,Khantzian, E.J., Halliday, K.S., & McAuliffe, W.E. (1990). Addiction and the vulnerable self: Modified dynamic group therapy for drug abusers. New York: Guilford Press. and finally all drugs of addiction.Khantzian, E.J. (1999). Treating addiction as a human process. Northvale, NJ: Jason Aronson. According to Khantzian's view of addiction, drug users compensate for deficient ego function by using a drug as an "ego solvent", which acts on parts of the self that are cut off from consciousness by defense mechanisms. According to Khantzian, drug dependent individuals generally experience more psychiatric distress than non-drug dependent individuals, and the development of drug dependence involves the gradual incorporation of the drug effects and the need to sustain these effects into the defensive structure-building activity of the ego itself. The addict's choice of drug is a result of the interaction between the psychopharmacologic properties of the drug and the affective states from which the addict was seeking relief. The drug's effects substitute for defective or non-existent ego mechanisms of defense. The addict's drug of choice, therefore, is not random. While Khantzian takes a psychodynamic approach to self-medication, Duncan's model focuses on behavioral factors. Duncan described the nature of positive reinforcement (e.g., the "high feeling", approval from peers), negative reinforcement (e.g. reduction of negative affect) and avoidance of withdrawal symptoms, all of which are seen in those who develop problematic drug use, but are not all found in all recreational drug users. While earlier behavioral formulations of drug dependence using operant conditioning maintained that positive and negative reinforcement were necessary for drug dependence, Duncan maintained that drug dependence was not maintained by positive reinforcement, but rather by negative reinforcement. Duncan applied a public health model to drug dependence, where the agent (the drug of choice) infects the host (the drug user) through a vector (e.g., peers), while the environment supports the disease process, through stressors and lack of support.Duncan, D.F. (1975). The acquisition, maintenance and treatment of polydrug dependence: A public health model. Journal of Psychedelic Drugs, 7, 209-213. http://www.duncan-associates.com/PUBLICHEALTHMODEL.htm Khantzian revisited the SMH, suggesting there is more evidence that psychiatric symptoms, rather than personality styles, lie at the heart of drug use disorders. Khantzian specified that the two crucial aspects of the SMH were that (1) drugs of abuse produce a relief from psychological suffering and (2) the individual's preference for a particular drug is based on its psychopharmacological properties. The individual's drug of choice is determined through experimentation, whereby the interaction of the main effects of the drug, the individual's inner psychological turmoil, and underlying personality traits identify the drug that produces the desired effects. Meanwhile, Duncan's work focuses on the difference between recreational and problematic drug use.Duncan, D.F., & Gold, R.S. (1983). Cultivating drug use: A strategy for the 80s. Bulletin of the Society of Psychologists in Addictive Behaviors, 2, 143-147. http://www.addictioninfo.org/articles/263/1/Cultivating-Drug-Use/Page1.html Data obtained in the Epidemiologic Catchment Area Study demonstrated that only 20% of drug users ever experience an episode of drug abuse (Anthony & Helzer, 1991), while data obtained from the National Comorbidity Study demonstrated that only 15% of alcohol users and 15% of illicit drug users ever become dependent.Anthony, J., Warner, L., & Kessler, R. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances and inhalants: Basic findings from the National Comorbidity Study. Experimental and Clinical Psychopharmacology, 2, 244-268. A crucial determinant of whether a drug user develops drug abuse is the presence or absence of negative reinforcement, which is experienced by problematic users, but not by recreational users.Nicholson, T., Duncan, D.F., & White, J.B. (2002). Is recreational drug use normal? Journal of Drug Use, 7, 116-123. http://www.duncan-associates.com/Is-Recreational-Drug-Use-Normal.pdf According to Duncan, drug dependence is an avoidance behavior, where an individual finds a drug that produces a temporary escape from a problem, and taking the drug is reinforced as an operant behavior. Specific mechanisms Some mental illness sufferers attempt to correct their illnesses by use of certain drugs. Depression is often self-medicated with alcohol, tobacco, cannabis, or other mind-altering drug use.Self-Medication With Alcohol and Drugs by Persons With Severe Mental Illness While this may provide immediate relief of some symptoms such as anxiety, it may evoke and/or exacerbate some symptoms of several kinds of mental illnesses that are already latently present,Mental Illness: The Challenge Of Dual Diagnosis and may lead to addiction/dependence, among other side effects of long-term use of the drug. Sufferers of post-traumatic stress disorder have been known to self-medicate, as well as many individuals without this diagnosis who have suffered from (mental) trauma.Post Traumatic Stress Disorder Due to the different effects of the different classes of drugs, the SMH postulates that the appeal of a specific class of drugs differs from person to person. In fact, some drugs may be aversive for individuals for whom the effects could worsen affective deficits. CNS depressants Alcohol and sedative/hypnotic drugs, such as barbiturates and benzodiazepines, are central nervous system (CNS) depressants that lower inhibitions via anxiolysis. Depressants produce feelings of relaxation and sedation, while relieving feelings of depression and anxiety. Though they are generally ineffective antidepressants, as most are short-acting, the rapid onset of alcohol and sedative/hypnotics softens rigid defenses and, in low to moderate doses, provides relief from depressive affect and anxiety. As alcohol also lowers inhibitions, alcohol is also hypothesized to be used by those who normally constrain emotions by attenuating intense emotions in high or obliterating doses, which allows them to express feelings of affection, aggression and closeness. People with social anxiety disorder commonly use these drugs to overcome their highly set inhibitions.Sarah W. Book, M.D., and Carrie L. Randall, Ph.D. Social anxiety disorder and alcohol use. Alcohol Research and Health, 2002. Psychostimulants Psychostimulants, such as cocaine, amphetamines, methylphenidate, caffeine, and nicotine, produce improvements in physical and mental functioning, including increased energy and feelings of euphoria. Stimulants tend to be used by individuals who experience depression, to reduce anhedonia and increase self-esteem. The SMH also hypothesizes that hyperactive and hypomanic individuals use stimulants to maintain their restlessness and heighten euphoria. Additionally, stimulants are useful to individuals with social anxiety by helping individuals break through their inhibitions. Opiates Opiates, such as heroin and morphine, function as an analgesic by binding to opioid receptors in the brain and gastrointestinal tract. This binding reduces the perception of and reaction to pain, while also increasing pain tolerance. Opiates are hypothesized to be used as self-medication for aggression and rage. Opiates are effective anxiolytics, mood-stabilizers, and anti-depressants, however, people tend to self-medicate anxiety and depression with depressants and stimulants respectively, though this is by no means an absolute analysis. Cannabis Cannabis is paradoxical in that it simultaneously produces stimulating, sedating and mildly psychedelic properties and both anxiolytic or anxiogenic properties, depending on the individual and circumstances of use. Depressant properties are more obvious in occasional users, and stimulating properties are more common in chronic users. Khantzian noted that research had not sufficiently addressed a theoretical mechanism for cannabis, and therefore did not include it in the SMH. Cannabis is commonly used to self-medicate individuals with attention deficit hyperactivity disorder, which has shown to improve symptoms for individuals with ADHD in studies.Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. NIH Consensus Statement Online 1998 Nov 16-18; 16(2): 1-37. Accessed October 2011. Effectiveness Self medicating excessively for prolonged periods of time with benzodiazepines or alcohol often makes the symptoms of anxiety or depression worse. This is believed to occur as a result of the changes in brain chemistry from long-term use. Of those who seek help from mental health services for conditions including anxiety disorders such as panic disorder or social phobia, approximately half have alcohol or benzodiazepine dependence issues. Sometimes anxiety precedes alcohol or benzodiazepine dependence but the alcohol or benzodiazepine dependence acts to keep the anxiety disorders going, often progressively making them worse. However, some people addicted to alcohol or benzodiazepines, when it is explained to them that they have a choice between ongoing poor mental health or quitting and recovering from their symptoms, decide on quitting alcohol or benzodiazepines or both. It has been noted that every individual has an individual sensitivity level to alcohol or sedative hypnotic drugs, and what one person can tolerate without ill health, may cause another to suffer very ill health, and even moderate drinking can cause rebound anxiety syndrome and sleep disorders. A person suffering the toxic effects of alcohol will not benefit from other therapies or medications, as these do not address the root cause of the symptoms. Infectious disease Self-medication with antibiotics is commonplace in some countries, such as Greece. Such use is cited as a potential factor in the incidence of certain antibiotic resistant bacterial infections in places like Nigeria. In a questionnaire designed to evaluate self-medication rates amongst the population of Khartoum, Sudan, 48.1% of respondents reported self-medicating with antibiotics within the past 30 days, 43.4% reported self-medicating with antimalarials, and 17.5% reported self-medicating with both. Overall, the total prevalence of reported self-medication with one or both classes of anti-infective agents within the past month was 73.9%. Furthermore, according to the associated study, data indicated that self-medication "varies significantly with a number of socio-economic characteristics" and the "main reason that was indicated for the self-medication was financial constraints". Similarly, in a survey of university students in Southern China, 47.8% of respondents reported self-medicating with antibiotics. Physicians and medical students In a survey of West Bengal, India undergraduate medical school students, 57% reported self-medicating. The type of drugs most frequently used for self-medication were antibiotics (31%), analgesics (23%), antipyretics (18%), antiulcerics (9%), cough suppressants (8%), multivitamins (6%), and anthelmintics (4%). Another study indicated that 53% of allopathic physicians in Karnataka, India reported self-administration of antibiotics. Children A study of Luo children in western Kenya found that 19% reported engaging in self-treatment with either herbal or pharmaceutical medicine. Proportionally, boys were much more likely to self-medicate using conventional medicine than herbal medicine as compared with girls, a phenomenon which was theorized to be influenced by their relative earning potential. Regulation Self-medication is highly regulated in much of the world and many classes of drugs are available for administration only upon prescription by licensed medical personnel. Safety, social order, commercialization, and religion have historically been among the prevailing factors that lead to such prohibition. Self medication with alcohol Self medication and drugs of addiction ----- See also * Biodiversity and drugs * Comfort food * Drug self administration * Drug therapy * Dual diagnosis * Placebo effect * Psychological trauma * Zoopharmacognosy References & Bibliography Key texts Books *Albanese, M. 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Access to care and medication use among the ambulatory elderly in Rio de Janeiro, Brazil: Dissertation Abstracts International. *Ostrowsky, M. K. (2007). Extending khantzian's self-medication hypothesis: An examination of low self-esteem, depression, alcohol use, marijuana use, and violent behavior. Dissertation Abstracts International Section A: Humanities and Social Sciences. *Pabon, T. M. (2004). The self-medication theory of addictive disorders: Motivational aspects of drug addiction. Dissertation Abstracts International: Section B: The Sciences and Engineering. *Rice, M. A. (1998). Concordant and discordant drug use in intimate relationships: A longitudinal study. Dissertation Abstracts International: Section B: The Sciences and Engineering. *Robinson, R. J. (2008). Comorbidity of alcohol abuse and depression: Exploring the self-medication hypothesis. Dissertation Abstracts International: Section B: The Sciences and Engineering. *Stawar, T. L. (1991). Perceptual learning style, modality-specific mnemonic elaboration strategies and achievement of severely psychiatrically disabled adults in self-medication management skills training: Dissertation Abstracts International. *Stockwell, L. M. (1993). A qualitative exploration of medication-taking behaviors in the elderly: Dissertation Abstracts International. External links * Self-Medication Hypothesis informational website. Category:Addiction Category:Alcohol abuse Category:Drug self administration Category:Coping Category:Drug addiction Category:Drug therapy Category:Pharmacy Category:Substance-related disorders